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HealthPartners

Coverage criteria policies

Benralizumab (Fasenra)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Fasenra® requires prior authorization for use from Pharmacy Administration.

Coverage

Benralizumab (Fasenra) is reserved for patient meeting all of the following criteria:

Severe Asthma:

  1. Patient is followed by an asthma specialist, allergist, or pulmonologist; and
  2. Prescribed within the FDA-approved dosing regimen; and
  3. Patient is 12 years and older with a pre-treatment serum eosinophil count of 150 cells/mcL or greater at screening (within previous 6 weeks); and
  4. Patient has poor asthma control (see criteria #5) despite the following standard therapies:
    1. Regular use of inhaled steroids (such as Flovent);and
    2. Regular use of a long-acting beta-agonist (such as Serevent); and
    3. Regular or periodic use of oral steroids; and
  5. Inadequate asthma control despite standard therapies is defined as one of the following:
    1. At least 2 exacerbations requiring oral systemic corticosteroids in the last 12 months, or
    2. At least 1 exacerbation treated in hospital or requiring mechanical ventilation in the last 12 months.

All authorizations will be for one year. Renewals will be provided annually with documentation that the medication is effective.

Definitions

Fasenra is an interleukin-5 receptor alpha-directed cytolytic monoclonal antibody (IgG1, kappa) indicated for the add-on maintenance treatment of patients with severe asthma aged 12 years and older, and with an eosinophilic phenotype.

Limitations of Use:

  • Not for treatment of other eosinophilic conditions.
  • Not for relief of acute bronchospasm or status asthmaticus.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPCS Codes

Codes

Description

J3590

Unclassified biologics

NDC Codes

Code

Description

00310-1730-30

Fasenra 30 MG/ML SOSY

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Fasenra Prescribing Information. AstraZeneca, Wilmington, DE, November 2017

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Policy activity

  • 02/05/2018 - Date of origin
  • 04/01/2018 - Effective date

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